Imran H. Yusuf

Imaging the Macula Through a Black Occlusive Intraocular Lens

B lack occlusive intraocular lens (IOL) insertion has been shown to be an effective treatment for intractable diplopia, visual confusion, and poor cosmesis resulting from leukokoria. A significant disadvantage of occlusive IOL insertion is that conventional funduscopy is not possible, preventing the detection of posterior pole disease. Here we describe a patient in whom we made the novel discovery of successful macular imaging through an occlusive IOL using an infrared light–based scanning laser ophthalmoscope/optical coherence tomography (OCT) scanner. We suggest that this report is likely to fundamentally change the current thinking on occlusive IOLs and to promote their use in the management of these patients.

Inability to perform posterior segment monitoring by scanning laser ophthalmoscopy or optical coherence tomography with some occlusive intraocular lenses in clinical use.

PURPOSE: To evaluate whether occlusive intraocular lenses (IOLs) produced by several manufacturers for clinical use equivalently transmit near‐infrared (IR) light for scanning laser ophthalmoscopy (SLO) or optical coherence tomography (OCT) imaging. SETTING: Nuffield Laboratory of Ophthalmology, Oxford University, United Kingdom. DESIGN: Evaluation of diagnostic test or technology. METHODS: The study evaluated 6 black IOLs of 2 designs: 3 poly(methyl methacrylate) (PMMA) and 3 iris‐claw anterior chamber IOLs. Each IOL was placed between a broad‐spectrum white light source and a spectroradiometer to generate transmission spectra. Transmission in the near‐IR range was examined using an 850 nm light‐emitting diode. Scanning laser ophthalmoscopy or OCT imaging using Spectralis spectral‐domain SLO or OCT was attempted through occlusive IOLs in a model eye. RESULTS: Artisan iris‐claw and MS 612 PMMA occlusive IOLs totally occluded all wavelengths of light, including in the near IR range in which SLO and OCT imaging systems operate. It was not possible to capture SLO or OCT images through the iris‐claw and PMMA occlusive IOLs in a model eye. CONCLUSIONS: Results suggest the property of near‐IR transmission that permits SLO or OCT imaging through occlusive IOLs is restricted to the Morcher range of occlusive IOLs. Patients with non‐near IR transmitting IOLs will not be able to receive detailed posterior segment monitoring with SLO or OCT. This finding may have a significant impact on preoperative occlusive IOL selection and the management of current patients with occlusive IOLs. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Occlusive IOLs for Intractable Diplopia Demonstrate a Novel Near-Infrared Window of Transmission for SLO/OCT Imaging and Clinical Assessment

PURPOSE Occlusive intraocular lens (IOL) implantation is an effective therapeutic option in patients with intractable diplopia, visual confusion, and unsightly leukocoria. However, their use has been restricted by concerns that inability to visualize the retina may prevent the diagnosis of important posterior pole diseases. In this study, transmission spectra of occlusive IOLs were defined as a basis for acquiring scanning laser ophthalmoscopy/optical coherence tomography (SLO/OCT) images. METHODS Fifteen IOLs of three designs were examined: black small and large PMMA and black Lotus (Morcher GmbH, Stuttgart, Germany). Each IOL was placed between a broad-spectrum white light source and a spectroradiometer, to generate transmission spectra for each lens and determine the cutoff wavelength. Transmission in the near-infrared (NIR) range was confirmed with an 850-nm LED. A model eye was implanted with occlusive IOLs, and SLO/OCT scans were acquired with seven clinical SLO/OCT imaging systems. RESULTS Occlusive IOLs demonstrated high levels of transmission of NIR light. It was determined that most SLO/OCT scanners would achieve 99% to 100% transmission at their operational wavelengths of NIR light. Furthermore, all clinical SLO/OCT imaging systems were capable of imaging fine retinal features without attenuation through occlusive IOLs in a model eye. CONCLUSIONS In this study, a novel NIR window of high-level transmission was identified across the occlusive IOLs with applications to SLO/OCT imaging and NIR-based clinical assessment. The ability to acquire high-quality SLO/OCT scans to detect posterior pole disease may fundamentally change the current view on occlusive IOLs and encourage their use in patients with intractable diplopia.

Outpatient Ultra wide-field intravenous fundus fluorescein angiography in infants using the Optos P200MA scanning laser ophthalmoscope.

Purpose To determine the feasibility of Ultra wide-field intravenous fundus fluorescein angiography (UWF-IV-FFA) in infants. Methods A retrospective review of infants who underwent UWF-IV-FFA with the Optos P200MA was performed. The ability to capture different phases of the angiogram, the total image acquisition time and the presence of image artefacts were analysed. Results Twelve infants with a variety of proliferative retinopathies underwent UWF-IV-FFA over a 7-month period. The mean age was 3.4 months (range 2–6 months) and the mean image acquisition time was 4 min (range 3–5). Pseudocolour fundus images and the venous, recirculation and late phases of UWF-IV-FFA were captured successfully in all infants (100%). Choroidal and arterial phases were captured in one (8.3%) and 10 (83.3%) infants, respectively. Image artefacts due to eyelashes and corneal desiccation occurred in nine (75%) and six (50%) infants, respectively. No adverse medical problems were noted. Conclusions We have shown that UWF-IV-FFA can be successfully and safely performed in infants using the Optos P200MA system. It is a feasible new alternative to RetCam for obtaining an IV-FFA in the outpatients setting.

Heidelberg Spectralis Ultra-Widefield Fundus Fluorescein Angiography in Infants

PURPOSE To describe the intraoperative use of the Heidelberg Spectralis for ultra-widefield fundus fluorescein angiography in infants. DESIGN Retrospective observational case series. METHODS A modified Heidelberg Spectralis was used to perform ultra-widefield fundus fluorescein angiography in infants undergoing an examination under general anesthesia for a range of retinal vasculopathies. Peripheral angiographic findings, angiographic image acquisition time, and any complications were reviewed. RESULTS A total of 22 eyes of 11 infants underwent intraoperative ultra-widefield fundus fluorescein angiography using the modified Heidelberg Spectralis. Ultra-widefield fundus fluorescein angiography was successfully performed in all infants and permitted capture of the posterior pole as well as the peripheral retina in a single shot centered on the macula. Peripheral retinal pathologies captured include neovascularization, capillary nonperfusion, and skip areas from previous laser treatment. Capturing of angiographic images took a mean time of 7.09 minutes. Image artifact from condensation of the ultra-widefield lens was noted during imaging of 1 infant. CONCLUSIONS The modified Heidelberg Spectralis is an effective and reliable imaging tool for performing ultra-widefield fundus fluorescein angiography in infants. It is capable of capturing wide-angle images of high quality. The technique has advantages as an alternative to RetCam fluorescein angiography in infants undergoing an examination under general anesthesia.

Transient retinal artery occlusion during phacoemulsification cataract surgery.

PurposeTransient retinal artery occlusion (TRAO) is a potentially underdiagnosed cause of immediate ‘pad off’ visual loss following phacoemulsification cataract surgery under sub-Tenon’s anaesthesia.MethodsWe describe a series of three patients presenting with enigmatic ‘pad off’ visual loss following phacoemulsification surgery, each diagnosed with TRAO. We describe the variable clinical presentation, illustrate the value of optical coherence tomography (OCT) imaging in establishing the diagnosis, and present the final visual outcomes.ResultsClinical findings alone may be subtle and inadequate in localising the pathology in patients with TRAO. Cross-comparison of superior and inferior macula OCT profiles in branch-pattern arterial occlusion—and between healthy and affected eyes in central-pattern arteriolar occlusion—is critical in clinching the diagnosis. The typical evolution of OCT appearance is acute-phase inner retinal thickening/oedema and hyperreflectivity followed by progressive, late-phase inner retinal atrophy. Visual acuity may recover but central scotomas, and defects in colour perception may persist.ConclusionThe diagnosis of TRAO is challenging; delayed presentation may resolve fundal and retinal angiographic abnormalities. OCT may be the only imaging modality that can provide objective evidence of TRAO. Meticulous comparison/segmentation of OCT images is therefore mandatory in patients presenting with acute post-operative visual loss to exclude TRAO.

Hydroxychloroquine retinopathy: an emerging problem

PurposeThe aim of this case series is to raise awareness of the emerging issue of serious retinal damage caused by the prolonged use of hydroxychloroquine (HCQ) and the importance of adequate and appropriate monitoring of visual function during treatment.Patient and methodsThis is a small retrospective case series of 3 patients on long-term HCQ who developed serious symptomatic retinal toxicity confirmed on imaging and functional testing.ResultsAll 3 patients were treated with HCQ for over 15 years; two for rheumatoid arthritis (RA), and the third for systemic lupus erythematosus (SLE). All 3 patients had macular involvement varying in severity confirmed with characteristic features on imaging and functional testing (Optical Coherence Tomography (OCT), Autofluorescence (AF) and Humphrey 10-2 visual fields).ConclusionHCQ is widely used to treat autoimmune conditions with a proven survival benefit in patients with SLE. However, long-term use can be associated with irreversible retinal toxicity. These cases highlight that HCQ, like chloroquine, can also cause visual loss in susceptible individuals. Early detection of presymptomatic retinal changes by the introduction of appropriate screening and monitoring is mandatory to limit the extent of irreversible visual loss due to HCQ retinal toxicity.

Juvenile-onset Normal Tension Glaucoma From Chronic, Recurrent Low Cerebrospinal Fluid Pressure.

Introduction:The evidence for low cerebrospinal fluid pressure (CSFP) as a key parameter in the pathogenesis of glaucoma is increasing. Primate models have demonstrated the onset normal tension glaucoma (NTG) from experimentally induced chronic intrathecal hypotension; an approach not possible in human subjects. Case Presentation:A 27-year-old man presented with a central scotoma in his left eye. He had undergone 8 CSF shunt revision procedures over a 25-year period secondary to recurrent low CSFP following surgical excision of a pinealoblastoma, aged 2. A focal nerve fiber layer defect was detected in the left eye associated with reduced retinal sensitivity on microperimetry. Three adjacent optic disc hemorrhages had been documented in the same position over an 18-month period. A diagnosis of left-sided NTG was made; the patient was started on Latanoprost 0.005%. A new generation CSF shunting device (ProGAV)—which neutralizes CSFP fluctuations analogously to trabeculectomy surgery for intraocular pressure—was considered necessary in this patient to alleviate persistent headaches and reduce the risk of progressive glaucomatous visual loss. Conclusions:This exceptional case illustrates how premature onset NTG may occur as a result of chronic, recurrent intrathecal hypotension—a “pure” human model. We describe an original management approach of implanting an adjustable, programmable CSF shunt valve (ProGAV) to reduce fluctuations in the translaminar cribrosa pressure difference, and reduce the risk of glaucomatous visual loss.

Black-on-black secondary occlusive IOL implantation to alleviate enigmatic light perception through a black IOL

UNLABELLED A 61-year-old woman presented with an 18-year history of a debilitating ghosting phenomenon and light perception in her right eye following implantation of a Morcher black intraocular lens (IOL) for intractable diplopia. On 5 occasions, she was referred to hospital ophthalmology, repeatedly requesting right optic nerve transection to alleviate the symptoms. The mechanism of light perception across the occlusive IOL remained enigmatic, preventing appropriate management. Morcher occlusive IOLs transmit high levels of near infrared (IR) light, which may cause light perception under photopic conditions by long-wavelength cone photoreceptors. Considering this, we implanted a near IR-blocking Artisan black iris-claw IOL anterior to the Morcher occlusive IOL. Postoperatively, the light perception and ghosting disappeared and the visual quality of life score (VF-14) increased from 41 to 86. We suggest consideration of this surgical approach of black-on-black IOL implantation for patients with refractory light perception despite implantation of a near IR-transmitting occlusive IOL. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.

A sticky sight: cyanoacrylate ‘superglue’ injuries of the eye

A 64-year-old man presented to casualty with blurred vision and pain in his left eye, 2 h after inadvertently instilling clear nail glue into his eye instead of postoperative Timolol eye drops. The glue was removed at the slit lamp revealing a corneal abrasion, which was managed with topical antibiotics. Inadvertent ocular cyanoacrylate, or ‘superglue’, instillation has been reported frequently since 1982 when superglue was repackaged into ophthalmic style dropper bottles. This case report highlights the continuing problem of cyanoacrylate eye injuries and serves as a reminder to healthcare professionals to report such incidents to manufacturers and regulatory bodies, on behalf of their patients, to promote the introduction of universal safety mechanisms on all household chemical containers. Failure of glue manufacturers to introduce safety cap mechanisms has resulted in significant ocular morbidity over the last 27 years, and such incidents are expected to occur until superglue bottles are redesigned.